Navigating Conflict in PE Using Strengths-Based Approaches
How did the air get there
1. How Did the Air Get There?
A Case Demonstrating Nuances in Procedural
Ultrasound
Free Open-Access Medical Education in Point of Care
Ultrasound
Produced by Pitt IM POCUS
2. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
3. Case info
A middle-aged man with no PMH p/w progressive shortness of breath x several
months. He normally has a “smoker’s cough” but recently his cough has
increased and he is finding it harder to breathe.
T 98, HR 98, BP 110/70, RR 20, SpO2 92% on 2L.
Exam revealed reduced breath sounds R chest, dullness to percussion of R
chest, reduced R sided tactile fremitus.
CXR revealed opacification of R hemithorax with slight left mediastinal shift.
Seemed c/w pleural effusion. POCUS was performed for better assessment of
pleural effusion.
4. Right lateral chest
• Interpretation?
• Limitations/Feedback on image quality
Probe marker pointed laterally Probe marker pointed superiorly
5. Case info
Thoracentesis was performed (for diagnostic purposes, as well as therapeutic
removal of fluid) at this site. 60 cc syringe was used to remove fluid, along with
tubing and 3-way stopcock to prevent air re-entry.
After 1.1 L was removed, air started to enter the syringe, in addition to a small
amount of fluid. All connections were inspected and all seals were tight, with
no leaks. Pt reporting feeling well. No cough or CP. Soon only air (no fluid) was
entering syringe with aspiration.
At this point procedure was stopped, occlusive dressing was placed over
catheter and catheter was removed. There was concern for pneumothorax, so
POCUS was performed (these next 4 are representative images)
6. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
7. Left Lung (L1)
• Interpretation?
• Limitations/Feedback on image quality
8. Right Lung (R1)
• Interpretation?
• Limitations/Feedback on image quality
11. Case info
Pt reported feeling better than before the procedure. Said he was breathing
comfortably. HR 66, BP 136/74, RR 16, SpO2 95% RA.
The following CXR was obtained soon after
12. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
13. Diagnostic and Management Discussion
What happened?
What are the next steps in diagnosis and management?
14. Overview
Case information
• What would be your diagnostic/management plan without POCUS?
• What are your POCUS question(s)?
Images
• What is your interpretation?
• Limitations of images? How could they be improved?
Diagnostic and management discussion
• What are the next steps in diagnosis and management?
Hospital Course/Learning Points
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
15. Hospital Course
This is a classic presentation of “Pneumothorax ex vacuo”
Because pt was doing so well, tube thoracostomy was not done urgently.
Thoracic surgery was consulted, and decision was made to observe. Pt did well.
Fluid studies were transudative. The effusion was felt to be due to non-
reexpandable lung, with subsequent effusion due to negative pressure. The
etiology was never determined.
16. Learning Points
1) Should US always be used for thora?
2) Causes of post-thoracentesis PTX
3) Physiology of PTX ex vacuo? how to recognize and manage?
4) Should we routinely measure pleural pressures during thora?
17. 1) Should POCUS always be used for thoracentesis?
Yes. According to SHM (with extensive literature backing)
• Reduce incidence of PTX and visceral laceration
• Increase success rate
• Identify complex pleural features, and quantify volume, to aid
decision-making
• Understand needle depth
https://www.journalofhospitalmedicine.com/jhospmed/article/157109/hospital-medicine/recommendations-
use-ultrasound-guidance-adult
18. 1) Should POCUS always be used for thoracentesis?
Yes. According to SHM (with extensive literature backing)
• Reduce incidence of PTX and visceral laceration
• Increase success rate
• Identify complex pleural features, and quantify volume, to aid
decision-making
• Understand needle depth
https://www.journalofhospitalmedicine.com/jhospmed/article/157109/hospital-medicine/recommendations-
use-ultrasound-guidance-adult
19. 1) Should POCUS always be used for thoracentesis?
https://www.journalofhospitalmedicine.com/jhospmed/article/157109/hospital-medicine/recommendations-
use-ultrasound-guidance-adult
20. 2) Causes of post-thoracentesis PTX
• Lung laceration by needle or catheter
• Bleb rupture
• Unintentional air entry through catheter
• Can prevent with 1-way tubing.
• Stopcock can help but not perfect
• Non-reexpandable lung (PTX ex vacuo)
https://emcrit.org/pulmcrit/pneumothorax-ex-vacuo-post-thoracentesis-pneumothorax-in-the-ultrasound-era/
21. 2) Causes of post-thoracentesis PTX
https://emcrit.org/pulmcrit/pneumothorax-ex-vacuo-
post-thoracentesis-pneumothorax-in-the-ultrasound-
era/
22. 3) Physiology of PTX ex-vacuo
• Non-reexpandable lung, with poor
visceral pleural compliance leads to
increasingly negative intrapleural
pressures with even with limited
additional volume removal.
• Aspiration --> negative intrapleural
pressure --> air entry from lung or along
catheter.
23. 3) Physiology of PTX ex-vacuo
Huggins. The Unexpandable Lung. F1000 Medicine Reports 2010, 2:77
http://f1000.com/reports/m/2/77
24. 3) Physiology of PTX ex-vacuo
Non-reexpandable lung can be due to
1) Trapped lung (thick visceral pleural rind). Maybe amenable to decortication or
2) Lung entrapment (collapsed portion of lung, often due to malignancy). Not for
decortication (note effusion often transudative, due to pressure mechanism)
25. Recognizing the illness script: Pneumothorax after large volume thoracentesis,
usually pt is stable.
Management
• Key point: Does not require emergent chest tube if pt clinically well. Take
your time to sort it out.
• Discussion is nuanced over small bore pigtail vs no drainage.
• Our practice would be to involve thoracic colleagues or other experts.
• May be utility to air-contrasted CT to assess pleural thickening
3) How to recognize and manage PTX ex-vacuo
26. In this case, immediate reaction to post-thora CXR was to worry, and consider
emergent chest tube.
But first step was to go back to the bedside and assess the patient.
Everything fit for PTX-ex-vacuo, so tube placement was not emergent, could
take time to make a good decision.
3) How to recognize and manage PTX ex-vacuo
27. 4) Should we routinely measure pleural pressures?
Data is equivocal. Might consider if concern for trapped lung.
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30421-
1/fulltext (Thanks to @BegMoeez for reference)
28. Case wrap-up
• What role did POCUS play in this case?
• How will you apply what you learned in your practice?
29. Take home points
• POCUS is key in performing thoracentesis
• PTX ex vacuo is an increasingly common cause of post-thora PTX in the
ultrasound era
• It is worth recognizing the illness script and understanding the physiology
and mgmt
30. Want to dive deeper into this case, or see more cases?
This case was presented by Pitt IM POCUS on twitter in May 2019. Follow this
link to see the full thread, including comments and discussion from the POCUS
MedTwitter community. We thank the MedTwitter community for
contributions to this thread.
Please follow us at @PittIMPOCUS
Follow this link for other case presentations
Any questions, please contact
Michelle Fleshner – mfleshner301@gmail.com
Steve Fox – stevefox00@gmail.com
31. This is free, open access medical education. You may download, share, modify,
and use freely when used for medical education.
Patient confidentiality is the priority in these cases, so details may be left out
or modified to prevent identification. An effort is made to maintain the
educational quality.
32. References/Additional Reading
• Farkas J. Pneumothorax ex vacuo: Post-thoracentesis pneumothorax in the
ultrasound era. September 17, 2014. EmCrit/PulmCrit blog. Link here
• Dancel, Ria, Daniel Schnobrich, Nitin Puri, Ricardo Franco-Sadud, Joel Cho, Loretta
Grikis, Brian P. Lucas, Mahmoud El-Barbary, Society of Hospital Medicine Point of
Care Ultrasound Task Force, and Nilam J. Soni. 2018. “Recommendations on the
Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the
Society of Hospital Medicine.” Journal of Hospital Medicine: An Official
Publication of the Society of Hospital Medicine 13 (2): 126–35. Link here
• Huggins, John T., Peter Doelken, and Steven A. Sahn. 2010. “The Unexpandable
Lung.” F1000 Medicine Reports 2 (October): 77. Link here
• Ponrartana, Skorn, Jeanne M. Laberge, Robert K. Kerlan, Mark W. Wilson, and Roy
L. Gordon. 2005. “Management of Patients with ‘Ex Vacuo’ Pneumothorax after
Thoracentesis.” Academic Radiology 12 (8): 980–86. Link here
